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East Tennessee State UniversityDigital Commons @ East
Tennessee State University
Electronic Theses and Dissertations Student Works
5-2007
Evaluating Satisfaction and Benefit from NutritionCounseling from a Registered Dietitian amongHead and Neck Cancer Patients ReceivingRadiation Therapy.Lori E. WatsonEast Tennessee State University
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Recommended CitationWatson, Lori E., "Evaluating Satisfaction and Benefit from Nutrition Counseling from a Registered Dietitian among Head and NeckCancer Patients Receiving Radiation Therapy." (2007). Electronic Theses and Dissertations. Paper 2078. https://dc.etsu.edu/etd/2078
Evaluating Satisfaction and Benefit from Nutrition Counseling from a Registered
Dietitian among Head and Neck Cancer Patients Receiving Radiation Therapy
_____________________
A thesis
presented to
the faculty of the Department of Family and Consumer Sciences
East Tennessee State University
In partial fulfillment
of the requirements for the degree
Masters of Science in Clinical Nutrition
_____________________
by
Lori E. Watson
May 2007
_____________________
Elizabeth Lowe, Chair
Jamie Kridler, PhD
Alison Schaefer
Keywords: cancer, nutrition counseling, weight loss, side effects, radiation
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ABSTRACT
Evaluating Satisfaction and Benefit from Nutrition Counseling from a Registered
Dietitian among Head and Neck Cancer Patients Receiving Radiation Therapy
by
Lori E. Watson
The purpose of this study was to determine if patients with head or neck cancer
receiving radiation were satisfied with the nutrition counseling they were receiving and if
they obtained any benefit. Radiation to the head or neck region promotes side effects
such as taste changes and chewing and swallowing difficultly that decrease food and
fluid intake. A reduction in nutrients leads to weight loss, and weight loss in cancer
patients increases the risk of morbidity and morality as well as decreases quality of life.
Subjects were recruited from a local cancer treatment facility and a survey was
administered. Subjects were found to manage the side effects better after counseling
from the registered dietitian, and a minimal amount of weight loss was observed.
Registered dietitians when incorporated into a radiation treatment facility can provide an
effective nutrition program targeted at reducing weight loss and improving quality of life.
3
CONTENTS
Page
ABSTRACT ............................................................................................................ 2
LIST OF TABLES.................................................................................................... 5
Chapter
1. INTRODUCTION ............................................................................................ 6
Statement of the Problem............................................................................. 6
Significance of the Problem ......................................................................... 6
Assumptions................................................................................................. 7
Limitations .................................................................................................... 8
Definitions..................................................................................................... 8
2. REVIEW OF LITERATURE ............................................................................ 10
Etiology of Malnutrition and Weight Loss...................................................... 10
Assessment of Nutritional Status/Requirements........................................... 13
Implications for Enteral Nutrition................................................................... 17
Nutrition Counseling ..................................................................................... 19
Summary ...................................................................................................... 25
3. DESIGN AND METHODOLODY...................................................................... 27
Subject Recruitment .................................................................................... 27
Instruments .................................................................................................. 27
Study Design ................................................................................................ 28
Data Analysis................................................................................................ 30
4. DATA/RESULTS.............................................................................................. 31
Subjects ....................................................................................................... 31
Eating/Drinking Habits .................................................................................. 31
4
Side Effects .................................................................................................. 32
Weight Change............................................................................................. 33
Printed Educational Materials ....................................................................... 34
Energy Levels............................................................................................... 34
Supplement Use ........................................................................................... 34
Satisfaction................................................................................................... 35
Qualitative Data ............................................................................................ 35
5. DISCUSSION, CONCLUSIONS, RECOMMENDATIONS .............................. 37
Discussion ................................................................................................... 37
Conclusions.................................................................................................. 40
Recommendations........................................................................................ 40
REFERENCES........................................................................................................ 41
APPENDICES ......................................................................................................... 43
Appendix A: Nutrition Care Survey ............................................................... 43
Appendix B: Data Analysis ........................................................................... 47
VITA................ ........................................................................................................ 52
5
LIST OF TABLES
Tables
1. Side effects reported by participants ........................................................ 32
2. Side effects reported after nutritional counseling...................................... 33
3. Weight change for participants ................................................................. 33
4. Advice to future patients ........................................................................... 35
5. Responses to unexpected experiences.................................................... 36
6
CHAPTER 1
INTRODUCTION
Statement of the Problem
The purpose of this study was to determine if patients with head or neck cancer
receiving radiation were satisfied with the nutrition counseling they were receiving and if
they obtained any benefit. Oral and pharyngeal cancer rank among the most common
cancers in the US; 14th most common for women and 10th most common for men (1).
Cancer of the head and neck region, in contrast to other types of cancer, often causes
more nutritional problems for the individual because of the location of the malignancy.
Numerous studies have shown that there are two common nutritional concerns with all
cancer patients: malnutrition and weight loss. Malnutrition was defined by Allen and
Crocker (2) as “any nutritional deficit associated with an increased risk of morbidity and
mortality.” The prevalence of cancer patients who are malnourished can range from
40% to almost 80%, and more often than not, patients with malnutrition caused by head
or neck malignancies are on the upper end of this range (3, 4).
Significance of the Problem
Malnutrition and weight loss can play key roles in determining an individual’s
experience during treatment and response to treatment along with the survival rate (2).
Malnutrition alone increases the patient’s risk of infection, treatment side effects, and
health-care costs for the individual and for the hospital. Malnutrition may decrease life
expectancy and quality of life (4). Research has found that the five-year survival rate for
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head and neck cancer is 53% (1). Thus, it is important to offer the best and most
effective care to promote increased survival rates and improve quality of life.
Even though the long-term survival statistics can seem discouraging for patients,
current research findings are helpful in suggesting ways for healthcare providers to
enhance quality of life and improve survival rates. Recent studies examined the effects
of different treatment options, nutrition counseling techniques as well as nutrition
support routes and formulas to strengthen and improve upon the experience and
response to radiation and chemotherapy treatment. Researchers are trying to better
understand the mechanism causing cancer patients to experience such dramatic weight
loss when compared to patients with other diseases as well as how to combat these
issues before and during treatment. Encompassing all the aspects of cancer treatment,
from nutritional interventions to emotional turmoil will improve the outcome not only for
individuals with head and neck cancer but any individual battling cancer.
Assumptions
It is assumed that individuals who indicate an improvement in side effects after
nutrition counseling from a registered dietitian received benefit from the nutrition
counseling.
Benefit from nutrition counseling improves quality of life during radiation treatment.
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Limitations
Only patients receiving radiation therapy to the head or neck region participated in the
research study.
Patients being fed entirely by enteral feedings were excluded.
Research took place in only one of the radiation therapy treatment facilities as
opposed to multiple facilities in the geographic region.
The sample size of participants was small.
Definitions
Pharyngeal (pharynx) – the throat, serves as a passage way for respiratory and
digestive tracts. Divided into the nasopharynx, oropharynx, and laryngopharynx (5)
Enteral feedings – the introduction of nutrients directly into the GI tract by feeding tube
(5)
Malignancy – a cancer (5)
Stomatitis – an inflammation of the mucous membranes of the mouth (5)
Esophagitis – inflammation of the mucosal membrane of the esophagus (5)
Mid-arm muscle circumference – a measurement of the circumference of the arm at a
midpoint between the shoulder and the elbow. It is an indication of upper arm muscle
wasting (5)
Edema – abnormally large amounts of fluid in the body (5)
Albumin – a protein found in blood that serves as a carrier protein. Used in laboratory
testing as an indicator of protein status and inflammation (5)
9
Resting energy expenditure (REE) – an equation used to measure the amount of
energy used during a resting state
Tracheotomy – an incision made in the trachea through the neck below the larynx,
performed to gain access to the airway below a blockage with a foreign body or tumor
(5)
Flap reconstruction – an alternative to skin expansion as a method of breast
reconstruction after a mastectomy (5)
Dysphagia – difficulty in swallowing (5)
Squamous cell carcinoma – a slow growing malignant tumor of squamous epithelium (5)
Xerostomia – dryness of the mouth caused by cessation of normal salivary secretion (5)
Mucositis – any inflammation of a mucous membrane, such as the lining of the mouth
and throat (5)
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CHAPTER 2
REVIEW OF LITERATURE
Etiology of Malnutrition and Weight Loss
It is essential for patients and healthcare professionals to understand that weight
loss associated with any cancer is mulitfactorial (6). According to Capra, Ferguson, and
Reid (3) “Malnutrition can result from the systemic effects of the tumor, the local effects
of the tumor, or the side effect of anti-cancer treatments.” Nitenberg and Raynard (7)
described weight loss as a result of the ‘parasitic’ metabolism of the tumor on the host
that impacts the metabolism of the host. Regardless of how the tumor affects those with
cancer, the result is weight loss. Examples of ways the tumor may promote weight loss
include anorexia and altered metabolism, but the effects may differ depending on the
type and the complexity of the cancer (3). Local effects of the malignancy consist of
malabsorption, obstruction, and diarrhea/vomiting (3). These four occurrences often
decrease the individual’s nutrient intake while increasing nutrient excretion from the
body, leading to weight loss and ultimately malnutrition if these symptoms are allowed
to continue for even a short period of time (8).
A form of weight loss called cachexia is a condition often seen and studied in
association with cancer. Early studies (8, 9) of cachexia in people with cancer were
thought to be the outcome of a nutritional deficit caused by energy use by the tumor.
Additionally, decreased nutrient intake was attributed to the tumor acting on the satiety
sensation in the central nervous system, resulting in starvation. In thinking this was the
weight loss mechanism, the most rational way to combat it was to attempt to increase
intake in individuals (9). Healthcare providers soon discovered that regardless of how
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many patients increased their intake, they continued to lose weight. This conclusion led
to the identification of the phenomenon known as primary anorexia/cachexia syndrome
(9). Cachexia is different from starvation in that during starvation there is a decreased
intake of energy leading to decreased metabolism to conserve vital tissues, and fat is
used for energy before lean tissue (8). Cachexia is coupled with an altered inflammatory
state where catabolism is accelerated regardless of the nutrient intake, and peripheral
proteins and lipids are mobilized for energy (9). Metabolism does not slow down as it
does in starvation, and the end result is loss of fat and lean body mass, namely skeletal
muscle (9).
Along with the metabolic alterations to address during cancer, there are several
physical symptoms contributing to weight loss as well. Capra, Ferguson, and Reid (3)
found in their research that 40% to 60% of individuals receiving radiation to the head or
neck experienced swallowing problems because of stomatitis and esophagitis. When
these symptoms presented, individuals complained of pain and bleeding that decreased
and/or altered nutritional intake dramatically (3).
For people with head and neck cancer, changes in taste sensation are often the
most common side effect of cancer treatment. Research has shown that 14% of
individuals had taste changes before radiation treatments began and 84% developed
changes by the fifth week of radiation therapy (3). Initial taste change may be directly
affected by the tumor itself and is caused by an amino acid like substance secreted by
tumor cells (10). Taste sensation is experienced through a stimulation of taste receptors.
These receptors are located on the tongue in the form of taste buds, between the hard
and soft palates, the throat, and in the nasal cavity (10). Taste receptors are sensitive to
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five basic flavors. These include sweet, salty, bitter, sour, and acid, and the less familiar
umami, which offers enhancement of the savory flavors (10). During therapy, taste
changes occur because of cell damage when the radiation is directed at the head or
neck region whereby receptors die and taste is affected (10). Individuals describe
alterations in sweet, salty, bitter, and sour as being mild to completely absent (10). Bitter
is often the most affected, leading to the avoidance of meat, tea, and chocolate (10).
This may lead to a decrease in protein intake and ultimately result in muscle wasting
(10). If the tip of the tongue (where sweet receptors are located) is included in the path
of radiation, then the ability to detect sweetness may be hindered (10). Taste sensation
should return within two to four months after termination of the treatments (10).
In addition to taste loss with cell damage, the salivary production can be reduced
or absent during or after radiation therapy (10). Often the saliva will change consistency
from clear and watery to viscous and semi-opaque, thus impacting swallowing and taste
(3). It must be noted that taste and salivary changes do not only occur when an
individual endures radiation therapy. Studies showed that 36% to75% of individuals
receiving chemotherapy also experience taste change when certain chemotherapeutic
drugs are present in their anti-cancer regimen (10).
Taste changes not only increase the risk of weight loss, secondary to decreased
intake, but it may also have a psychological effect on the individual. Food plays a key
role in social activities, and when food does not taste as it “should”, individuals often
become depressed and avoid social interactions with friends and families. Ravasco (10)
reported that, “Forty percent of patients who reported that taste changes affected their
lives reported that they felt depressed.”
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Tony Peregrin (11) conducted a study in which he interviewed two oncology
registered dietitians, Bonnie Dixon and Barbara Grant, about ways of addressing taste
changes in patients with cancer. They suggested that foods with strong flavor should be
consumed cool or cold to reduce the aroma. If the smell of food while cooking makes
the individual sick, offer recipes for cold food or salads. Because tooth decay is
associated with dry mouth, a common side effect from radiation to the head or neck
region, the registered dietitians included recommendations for managing dry mouth,
such as visiting the dentist before starting their anti-cancer treatment to help increase
the enamel strength of the teeth (11). Additionally, frequently rinsing one’s mouth,
keeping water nearby all the time, keeping lips moist, brushing teeth after each meal or
snack, and reducing the amount of sugary or sticky foods consumed will also help
combat dry mouth and tooth decay. Dixon and Grant (11) also communicated the role of
the registered dietitian when caring for a person with cancer. Grant was quoted as
saying, “When providing nutritional counseling, a food and nutrition professional needs
to be proactive rather than reactive (11).”
Assessment of Nutritional Status/Requirements
By definition proactive means (12) “Serving to prepare for, intervene in, or control
an expected outcome or situation especially a negative or difficult one.” In being
proactive, healthcare professionals would need to assess specific factors that alert them
to an individual who was nutritionally deficient before treatment begins. One
assessment tool used in a number of studies was the subjective global assessment
(SGA). This questionnaire is a standardized tool developed to determine nutritional
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status in an easy, noninvasive, cost-effective way (13). After compiling the
questionnaire, the individuals were identified as either: well nourished,
moderately/suspectedly malnourished, or severely malnourished (13). The survey was
originally validated in surgical patients but has since been modified in order to assess
nutritional status of cancer patients (13).
A study performed by Thoresen et al. (13), attempted to validate the SGA
questionnaire as an assessment tool when compared to a conventional objective
assessment. A total of 46 patients were included for this three-month study. Nutritional
status was measured in two ways: 1) objective criteria such as anthropometric
measures of BMI, mid-arm muscle circumference (MAMC), and triceps skin fold (TSF)
along with protein assays, 2) by the use of subjective SGA questionnaire (13).
Malnutrition defined by Thoresen (13) included one or more of the following criteria:
weight loss >5% during last month or >10% during last 6 months or >15% of
prediagnosis weight, BMI <20, TSF < 5th percentile, MAMC < 5th percentile, serum
albumin < 3.0 g/L, and serum prealbumin < 0.21 g/L. The SGA defines each of its
malnutrition categories as follows: well nourished implies stable weight or increasing
weight because of improvement in symptoms; moderately/suspectedly malnourished
includes weight loss up to 10% during the last 6 months and eating less than usual; and
severely malnourished is greater than 10% loss of body weight during the last 6 months
and obvious signs of malnutrition such as muscle wasting and edema (13).
Results of this study showed that of the 46 patients involved, 38 of them had lost
weight, and more specifically 24 had lost more than 10% of their original body weight
(13). The SGA produced results that correlated highly with the objective criteria (BMI,
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MAMC, TSF, and laboratory assays). There were significant differences between the
SGA categories, meaning that participants matched accordingly to the defined
categories of malnutrition defined in the survey. The variables associated with the
objective tests estimate the body’s energy stores (13). The SGA had high relationships
with these variables, which proved the validity of the SGA. Researchers (13) noted there
was a weaker correlation with the SGA and measures of albumin and prealbumin. This
could lead to the conclusion that serum proteins are not a good indicator of nutritional
status but more of a benchmark of illness or inflammation (13).
The researchers pointed out that there are advantages of using the SGA as opposed
to the objective measures, one being that the questionnaire is more practical in a clinical
setting. Anthropometric methods take time and require staff who have been trained to
perform these measurements. Also the SGA listed contributory data for reasons of
weight loss. Questions about the individual’s symptoms were addressed and these
could be used to determine individualized nutrition counseling (13).
The SGA is only one tool of assessment available for use. Facilities may choose
to use a different assessment tool, but any general evaluation should include
assessment of the symptoms that may lead to weight loss, functional ability, physical
examination, use of supplements, of vitamins or of herbs, and current intake (8, 9).
Upon conducting the initial assessment, it would be necessary to use the
information to estimate the patient’s energy needs. Nutritional requirements for an
individual with cancer will depend upon the degree of malnutrition and the current state
of metabolic stress (14). Current resting energy expenditure (REE) can be increased,
decreased, or unchanged from prediagnosis REE (15). If there are no indicators of a
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change in energy expenditure, one is to assume it is normal (15). An article published in
the European Society for Clinical Nutrition and Metabolism by Arends et al. (15) noted
that in one quarter of individuals with cancer, when measured by indirect calorimetry,
were found to have 10% higher REE and in another one quarter of patients was 10%
lower than the predicted energy expenditure when measured by indirect calorimetry.
It is evident that there are no universal or standardized calculations for energy
requirements for individuals with cancer. Two studies (14, 15) mentioned the use of the
Harris Benedict and Schofield equations to calculate nutrient needs as well as a good
“rule of thumb”: 30 to 35 kilocalories per kilogram of body weight per day for individuals
who are ambulant and 20 to 25 kilocalories per kilogram of body weight per day for
those who are confined to bed. The alterations in protein metabolism are mentioned in
numerous studies, but again the degree of protein repletion depends upon the amount
of metabolic stress and the degree of malnutrition and wasting present in each
individual. Scheuren (14) suggested that protein needs might range from 1.2 to 2.0
grams per kilogram of body weight per day. Carbohydrate intake in healthy individuals
should range from 40% to 60% of the total energy intake. There are no current
recommendations for carbohydrate intake in people with cancer (14). Fat intake is very
important not only as an energy source but also for essential fatty acids and the
transport and absorption of the fat-soluble vitamins. Fat should not be restricted during
cancer treatments unless necessary (14).
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Implications for Enteral Nutrition
Enteral feedings may be indicated if the individual is unable to consume enough
nutrients orally because of reasons such as nausea, vomiting, taste changes, or in
cases of head and neck cancer, tumor obstruction. Feeding tubes may be placed
nasally or through the abdominal wall into either the stomach or the small intestine (8). A
study performed by Cheng, Terrell, and Bradford (16) found seven variables that
increase the probability of having an enteral feeding tube one month after completion of
treatment. These variables were as follows: a tumor in the oropharynx/hypopharyx
location; advanced stage cancers; tracheotomy; flap reconstruction; increased age;
chemotherapy; and decreased time since treatment (16). Various limitations were noted
in this. Information was collected at only one point in time, and there was no follow up.
No distinction was made between whether the individual had the feeding tube placed
before or during treatment. This information would be important to determine the
reasons for the initial placement of the feeding tube – to prevent weight loss or
complications in dysphagia (16). Despite its limitations, the study indicated several
factors that may increase the need for tube feeding placement and inform healthcare
professionals to be aware of these variables while performing assessments.
Several studies commented (4, 9, 15) that the evidence of providing nutritional
support to increase survival rates is controversial and inconclusive. However, numerous
studies (7, 9, 14, 15) suggest that enteral feedings may stabilize the deterioration of
nutritional status. Initiating early enteral feeding at the first indication of malnutrition or
early post-operatively, has been shown to decrease complications from surgery,
18
improve nitrogen balance, reduce protein catabolism, and reduce infections in cancer
patients (14).
A well-designed research study by Daly and colleagues (17) attempted to
compare nasogastric tube feeding with optimal oral nutrition in patients with head or
neck cancer. Forty patients were selected on the criteria of having measurable, local
advanced, inoperable, squamous cell carcinoma of the oral cavity, oropharynx, larynx,
or hypopharynx. Patients were stratified according to their cancer location, if they had
had previous head or neck cancer, and type of initial treatment. Each individual was
assessed using anthropometric measures, serum albumin levels, and 24-hour diet
recall. Toxicities defined by dysphagia, xerostomia, mucositis, nausea, vomiting,
constipation, and diarrhea were assessed in a patient interview with a registered
dietitian (17) and graded on a level of zero to four with zero being no toxicity, one being
slight toxicity, two indicating moderate toxicity, three being severe toxicity, and four
indicating life-threatening toxicity. For the group receiving oral nutrition, the goal nutrient
intake was 40 kilocalories per kilogram of body weight per day, and 1 to 1.5 grams of
protein per kilogram of body weight per day. All patients were given a diet pattern based
on their individual body weight, height, previous weight loss, age, and sex. Those who
needed additional intake were given commercial supplements as well as recipes to
enhance intake (17). The registered dietitian saw patients twice a week during their
eight-week radiation therapy treatment period. Individuals placed in the tube-feeding
group were given the same nutrition counseling during the initial treatment phase to
maximize caloric intake. When tube feedings were initiated, each patient was instructed
on the correct techniques of preparation of formulas, rates of administration, care, and
19
sanitation. Individuals were also given a booklet for home reference. Formulas and
rates were specified for each patient based on body weight, age, sex, height, and
degree of previous weight loss. The caloric target was the same as the oral nutrition
group at 40 kilocalories per kilogram of body weight per day and 1 to 1.5 grams of
protein per kilogram of body weight per day. The authors (17) evaluated calorie and
protein intake, weight changes, duration and amount of therapy received, severity of
reactions to therapies, patient acceptance, and complications that arose with nutritional
interventions. The results showed that there was an improvement in body weight in
individuals who received enteral feedings compared to those who were orally fed.
Nevertheless, there were no significant differences in the tumor response, duration of
response, or survival rate (17). Enteral feedings did not reduce toxicity levels, but they
may have lessened the magnitude of hindrance during daily activities. The enteral group
was also observed to take in more nutrients, 39 kilocalories per kilogram of body weight
per day versus 30 kilocalories per kilogram of body weight per day, when compared to
the orally fed group. Serum albumin levels indicating improved protein status also
returned to normal in the enterally fed group in contrast to the oral group (17). Overall,
the study showed promising results for enteral feedings for maintaining weight, serum
albumin level, and nutrient intake.
Nutrition Counseling
Nutrition is an important component when treating any disease or condition, so it
would be safe to assume that nutrition counseling should be part of any medical therapy
process. In the previous section, the research study by Daly (17) compared nutritional
20
counseling to tube feedings in helping reduce the rate of weight loss and increase oral
intake in people with cancer. The study showed that the group receiving the tube
feedings did increase the amount of nutrition they took in more than the group who did
not receive tube feedings, but it should be noted that nutritional counseling did help
patients keep their intake at 30 kilocalories per kilogram of body weight. This
information supports nutrition counseling as a necessary component in helping
individuals manage weight loss during their treatment.
Nutrition counseling has been shown through research to be very effective in
improving nutritional status, functional ability, and quality of life in cancer patients (18). A
study performed by Ravasco et al. (18) was one of the first to demonstrate that
individualized counseling, based upon food preferences was the most effective in
improving nutritional intake and quality of life when compared to a usual diet along with
liquid supplements and an intake ad libitum. As mentioned in the first section of this
paper, weight loss during treatment is an early marker of nutritional decline. The
smallest amount of weight loss in Ravasco’s study was seen in the group receiving the
individualized nutrition counseling (18). This group was also able to maintain energy
intake during treatment and into the follow-up period (three months following completion
of radiation treatment), while the other two groups either returned to baseline status or
fell below (18). Within the conditions of this clinical investigation, individualized nutrition
counseling during radiation treatment was the most influential to ensure a sustained and
adequate diet that was able to overcome the weight loss associated with radiation.
According to Ravasco (19), “Quality of life is a subjective multidimensional
construct representing functional status, psychological well-being, health perceptions
21
and disease/treatment-related symptoms.” At the end of the three-month follow-up
period the nutrition counseling group improved all the quality of life function scores in
the European Organization for Research and Treatment of Cancer (EORTC) Quality of
Life Questionnaire. The questionnaire was applied to measure participants’ physical,
emotional, cognitive, social role, and global health or quality of life levels during and
after their radiation treatment (18). Ravasco et al. (19) used the EORTC questionnaire to
evaluate quality of life in cancer patients. Patients were categorized into either high or
low risk for nutritional deficiencies. The high-risk group included individuals with
head/neck or gastrointestinal cancer. Low-risk was any other cancer location that could
be treated by radiation. Overall high-risk individuals presented with poorer scores for
quality of life than did those in the low risk group (19). Two associations were found in
the analysis of the data. An association between worse nutritional status and worse
mobility or anxiety/depression was identified as well as an association between
anxiety/depression and nutritional intake (19). The authors noted the following,
“Nutritional intake improvement was identified as a major determinant of the quality of
life improvement registered at the end of the radiation treatment (19).” This study’s
conclusion concurs with the previous study that nutrition does play a key role in quality
of life outcomes.
Registered dietitians and other health professionals have known that nutrition is
an important component of quality care and treatment that contributes to better overall
outcomes. However, it is also necessary to recognize how a patient feels about the
importance of nutrition. Since the 1990s, research has shown that individuals with
cancer have asked for information about their disease, although the amount, timing, and
22
type of information varies and contains no correlation with the patient’s demographics or
choice of treatment (20). Information has been provided in various ways including
written, verbal, and audio or videotape, but the most common is written. Written
education can be a valuable resource, but patient’s understanding and accuracy of the
information decide the patient’s satisfaction with the written material.
Hartmuller and Desmond (20) performed a cross-sectional study to discover the
nutritional needs of people with cancer as well as providing useful data to design
successful approaches to educating people with cancer about their nutritional needs. A
convenience sample of healthcare professionals, both registered nurses (RN) and
registered dietitians (RD), were surveyed to establish their perceptions about nutritional
needs of individuals with cancer during treatment. Six hundred sixty-six questionnaires
were filled out by RNs who visited the National Cancer Institute exhibit at the 1996
Oncology Nursing Society Annual Congress. Two different sampling methods were
performed to produce a representative sample of RDs. One hundred eighty
questionnaires were distributed at the National Cancer Institute exhibit at the 1996
American Dietetic Association Meeting and 195 questionnaires were returned by mail
after placing them in the newsletter of the Oncology Nutrition Dietetic Practice Group
(20). Eligibility criteria included a bachelor’s degree, appropriate healthcare professional
licensure, direct contact with patients during cancer treatment, and completion of all
items on the questionnaire (20). Patient recruitment was also acquired through
convenience sampling. Twelve institutions agreed to ask patients to participate in the
study and 653 people with cancer seen in outpatient treatment facilities agreed to
participate.
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A 16-item questionnaire for the healthcare professionals was developed and
designed by the researchers to measure constructs that would indicate differences in
opinions between RNs and RDs (20). It was reviewed by a panel consisting of one RD,
one RN, and two health educators from the National Cancer Institute Office of Cancer
Communications (20). The first four items on the questionnaire dealt with demographics
and education-related characteristics, followed by four items questioning the
perceptions of the respondent about the dietary needs of their patients. Another
question asked respondents to indicate the most preferred format for providing nutrition
information, while another asked them to rank how important it was to receive different
types of nutrition information. In conclusion, participants were asked to list the key items
they felt should be appear on printed material; responses included, “coping with side
effects resulting from treatment, tips for eating a balanced diet during cancer treatment,
glossary of terms, hints to increase calories and protein, resources in the community,
special dietary guidelines, suggested recipes, and use of nutritional supplements (20).”
Hartmuller and Desmond created a 28-item questionnaire to be administered to
the subjects with cancer. The panel that reviewed the healthcare professional
questionnaire also reviewed the patient questionnaire for literacy level and content and
face validity (20). The first six questions on the patient questionnaire related to
demographic data. The next four items were designed similarly to the healthcare
professional’s survey to elicit the perceptions of what the patients felt was important
about their nutritional needs during cancer treatment. There were two questions
different from the healthcare professional’s questionnaire asking if there were other
methods of receiving education other than printed materials, and which of those was the
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most preferred, as well as if the patients had any comments on cancer or its treatments
to offer the authors (20).
Results of this study showed that all three groups (RNs, RDs, and patients)
agreed that written material was the most effective way for providing/receiving
education, leading to the conclusion that an all-inclusive booklet should be provided by
healthcare professionals (20). Recipes were regarded with high importance in people
with cancer and should be available to individual patients. RDs indicated that people
with cancer would favor one-sheet education handouts. This differed from the opinions
of RNs and patients. This may be the result of RDs providing individualized nutritional
counseling and wanting to focus on primary eating problems, while RNs may not have
the time to focus on one problem but must address all issues in one counseling session.
The top three nutrition concerns agreed upon by all three groups were: appetite
loss; nausea and/or vomiting; and the ability to obtain enough nutrients (20). Patients
expressed being concerned about vitamin supplementation, but this concern was not
cited in either of the healthcare professional groups (20). RNs and RDs were found to
value information related to tips for family members, information on previously described
diets, and community resources more so than patients (20). Authors attributed this to
family members of the individual with cancer being more interested in this kind of
information rather than the patients themselves; the healthcare professionals were
aware of that need. There was a consensus on the items to be included when
healthcare professionals address people with cancer and they included: coping with
side effects, eating a balanced diet, increasing calories and protein, and any other
special dietary guidelines (20). Weight loss was a concern expressed by the healthcare
25
professionals but not by people with cancer; however, male patients were more
concerned with weight loss than female patients (20). It was noted that in this study
almost 50% of patients had weight loss at the time of diagnosis and did not receive
professional nutritional counseling (20).
This study created a vast amount of valuable data related to the opinions of
healthcare professionals and people with cancer that could be applied to the practice of
nutrition. The most startling statistic generated by this research was that almost 50% of
patients had weight loss and did not receive nutrition counseling. Healthcare
professionals must be aware of this and make an attempt to offer individualized
nutritional counseling by a registered dietitian. It was also learned that there were
differences in opinions between healthcare professionals and people with cancer
dealing with content of nutrition education. RDs and RNs should be cognizant of each
patient’s desire for education and schedule a personalized nutrition counseling session
if such action is possible.
Summary
In summary, the literature available has given healthcare professionals an insight
to how nutrition and nutrition counseling can be effective in helping people with cancer
minimize side effects of treatments and maximize their overall health. Individuals
receiving radiation to the head or neck often lose weight and become malnourished
because of radiation therapy side effects such as taste changes, pain when swallowing,
nausea and vomiting, malabsorption, and loss of appetite. Assessments of patients
should include functional ability, physical examination, current intake, and symptoms
26
that might lead to weight loss; these must be implemented early in the individual’s care
to minimize the risk of morbidity and mortality associated with malnutrition. The
subjective global assessment (SGA) was a useful tool in assessing cancer patients and
was validated by Thoresen and colleagues (13). Individuals with cancer may not require
more calories or protein than a normal individual, but steps must be taken to ensure that
they receive optimal nutrition to maintain weight. Enteral feedings, if initiated early, may
help decrease the incidence of weight loss. Daly et al. (17), found that when tube
feedings were compared to oral feedings, patients were able to maintain weight better
by keeping nutrient intake at 39 kilocalories per kilogram of body weight per day.
Nutrition counseling is a valuable resource for people with cancer, and research
has shown that it can improve quality of life by introducing ways to manage side effects
caused by radiation therapy. By improving symptoms that cause patients to have a
decrease in intake, their ability to perform day-to-day activities increases, thereby giving
them a better and more hopeful outlook on life. Opinions on what should be included in
nutrition counseling were similar between RNs, RDs, and people with cancer. These
three groups also agreed that written information was the most effective way to educate
people with cancer about their disease as well as providing them information on how to
manage the symptoms associated with head and neck radiation therapy.
27
CHAPTER 3
DESIGN AND METHODOLOGY
Subject Recruitment
From November 2006 to February 2007 all individuals seeking cancer treatment
through radiation therapy to the head or neck region at the Regional Cancer Center in
Johnson City, Tennessee were invited to participate in the study. This population was
desired for study participants specifically because radiation to the head and neck often
causes symptoms that decrease nutrient intake, resulting in weight loss. The desired
convenience sample size was set at 30 participants. Criteria for inclusion in the study
were any patient over the age of 18 receiving radiation to the head or neck region and
fed via oral feedings. Any individual receiving nutrition exclusively through alternative
routes (enteral feedings) was excluded. Individuals were not required to give written
informed consent, but verbal consent was made when they agreed to participate in the
research study. The Institutional Review Board approved research.
Instruments
A survey was developed by the principle investigator, a registered dietitian, and
the director of the cancer treatment center to measure the benefit received from the
nutrition counseling during radiation treatment as well as if the participants were
satisfied with the information received (Appendix A). Questions were formulated based
on previous surveys found in the literature relating to benefit from nutrition counseling,
and also what the staff at the cancer center felt was most important to know. Before
28
introduction into the study, the survey was validated by a group of sixth grade students.
The 21-question survey asked participants about symptoms they experienced
throughout radiation and if the symptoms improved following education/counseling from
the registered dietitian. A Likert (17) scale was used to measure patient’s satisfaction,
with one being the least satisfied and five being the most satisfied as well as a question
on overall satisfaction using very satisfied, satisfied, unsatisfied, very unsatisfied. Age,
sex, and last level of education completed were asked to demographically describe the
sample. Knowing the last level of education patients had completed could be used to
help the registered dietitian evaluate the effectiveness of the information being
distributed at the Regional Cancer Center.
Study Design
Patients who met inclusion criteria were interviewed by the registered dietitian for
an initial nutrition assessment. Initial weight before treatment was obtained by standard
balance beam scales according to treatment center protocols. Taste changes and
swallowing problems were assessed through patient’s responses to questions from the
registered dietitian, and receptiveness regarding nutrition education was evaluated
within this initial interview. At that time the registered dietitian provided information
concerning the side effects of radiation the individual could expect to experience
throughout radiation therapy. Side effects discussed included, dry mouth, pain when
swallowing, mouth sores, taste changes, and constipation because of consistency
changes in the diet. Information was provided through written handouts and verbal
guidelines expressing methods on how to manage side effects, including foods to avoid
29
and/or include in a soft diet, eating snacks between mealtimes, taking smaller bites at
meals, and recipes to increase calorie and protein content of foods. Throughout the
course of the individuals’ prescribed radiation treatment the registered dietitian
continued to see patients on a weekly basis, according to protocol at the Regional
Cancer Center. During these visits, the registered dietitian reassessed patients for
weight loss from initial assessment, any changes in nutrient intake, newly developed
constipation, taste changes, and swallowing problems. Commercial supplements were
available from the registered dietitian throughout the entire course of treatment and
were provided based upon nutritional need and willingness to try products. Upon
completion of their radiation therapy treatments, patients were asked by the registered
dietitian if they would like to participate in the study. The study was explained to
individuals as an evaluation of the nutrition counseling they received during their
treatment. It was also explained that the study would ask their opinion regarding the
nutritional information provided and its helpfulness in managing their side effects of
radiation treatment. Each individual was given a letter of explanation about the research
project as well as a questionnaire. The registered dietitian instructed subjects to
complete the questionnaire in the privacy of their home to decrease the feeling of
coercion from staff at the Regional Cancer Center. If patients chose to participate, they
completed the survey and returned it to the principle investigator via the self-addressed
stamped envelope that was provided for them. Subjects were instructed not to place
any identifying information (name and address) on the questionnaire to keep their
answers anonymous. Completed surveys and storage files were kept in a locked file
cabinet at the home of the principle investigator during the study. A control group was
30
not used in this study design as it is protocol to give nutrition counseling to all patients
who seek treatment at the Regional Cancer Center.
Data Analysis
Data collected from surveys were compiled and placed in an SPSS computer
program to evaluate the frequencies of answers for each individual question. Statistical
analysis was not appropriate for this study.
31
CHAPTER 4
DATA/RESULTS
Subjects
Five surveys were distributed to patients who met the inclusion criteria. Four
surveys were returned for an 80% response rate. The four subjects were described as
follows: 50% of the respondents were male, and 50%were female; two respondents
were in the age category of 56-65 years old, one was between 46-55 years old, and the
other was between 76-85 years old. The education levels for the participants were: two
of the participants (50%) had a middle school education, one (25%) participant had a
college education, and one (25%) had a high school education.
Eating/Drinking Habits
Two participants (50%) reported decreased food intake during radiation
treatments as well as consuming different foods than usual. After counseling from the
registered dietitian, three patients (75%) were able to increase consumption. One
patient said that there was more difficulty with eating. Three participants (75%) reported
increased fluid intake during treatments, while one (25%) reported less than usual fluid
intake. After counseling, two participants (50%) said they were able to drink more and
one (25%) person indicated that he/she was drinking about the same despite the
registered dietitian’s counseling. The fourth participant failed to answer if the registered
dietitian was able to affect fluid intake.
32
Side Effects
Results of responses from participants regarding side effects are located in
Tables 1 and 2. All participants described having taste changes and chewing problems
during radiation. Two subjects indicated that the dietitian helped with chewing
difficulties, and one did not give a response. Two subjects said they felt that the
registered dietitian helped them manage the taste change, while one subject did not
answer whether the registered dietitian had helped manage the taste change. Three
participants experienced swallowing problems during radiation therapy, and one
reported no swallowing problem. One respondent reported that the registered dietitian
helped manage his/her swallowing problem, and one subject did not give a response.
Two subjects described experiencing constipation and one reported no constipation. Of
the two patients who had constipation, one said that the education from the registered
dietitian helped, and one did not give a response.
Table 1. Side effects reported by participants
Taste ChangeSwallowing Problems
Chewing Problems
Constipation
Participant 1 Yes - Yes - Yes - Yes -
Participant 2 Yes - Yes - Yes - - -
Participant 3 Yes - Yes - Yes - Yes -
Participant 4 Yes - - No Yes - - No
33
Table 2. Side effects reported after nutritional counseling
Taste ChangeSwallowing Problems
Chewing Problems
Constipation
Participant 1* - - - - - - - -
Participant 2 - - - - - - - -
Participant 3 Yes - Yes - Yes - Yes -
Participant 4 Yes - - - Yes - - -
* Participants responses were omitted from data analysis
Weight Change
Three participants (75%) expressed a weight loss from the beginning of
treatment to the end of treatment. Table 3 indicates the amount of weight loss in each
individual participant as reported by the participant. One respondent (25%) did not
experience any weight change. The mean weight loss was 6.25 pounds.
Table 3. Weight change for participants
Weight Before Treatment (lbs)
Weight After Treatment (lbs)
Total Weight Loss (lbs)
Survey #1 196 184 12
Survey #2 150 150 0
Survey #3 178 177 1
Survey #4 140 128 12
34
Printed Education Materials
All four subjects (100%) reported receiving printed education materials from the
registered dietitian and all subjects responded that the educational materials were
helpful during their radiation treatments.
Energy Level
Two participants (50%) reported that they had a decrease in energy since
radiation treatment began, and two participants (50%) reported that they had not had a
decrease in energy. Of the two respondents who indicated less energy, one found that
after counseling from the registered dietitian he/she noticed an increase in energy, the
other found no change in energy levels. One participant did not have a decrease in
energy and after counseling found that there was no change in his/her energy levels.
The fourth participant did not answer if the registered dietitian had made a difference in
their energy levels.
Supplement Use
Subjects were asked if they had consumed any nutritional supplements or
vitamins during radiation treatment. Three respondents indicated the use of a
supplement. Two respondents indicated that they used Glucerna and Ensure, the third
did not indicate which supplement was consumed.
35
Satisfaction
When participants were asked if they were satisfied with how the registered
dietitian helped them maintain weight or decrease their weight loss, three subjects
(75%) responded that they were most satisfied with the registered dietitian and one
responded that he/she was satisfied. All four (100%) respondents were also very
satisfied with the nutrition counseling they had received as a whole.
Qualitative Data
Respondents were given the opportunity to give advice for patients taking
radiation in the future. Table 4 lists some of the responses:
Table 4. Advice to future patients
Listen to what your dietitian tells you. Write it down because you will forget.
Drink bottled water at room temperature.
Stop drinking carbonated soft drinks and coffee. You don’t need the sugar.
Start drinking Ensure with bananas.
Just hang in there. It goes by faster than you think.
I took pain medication and the mouthwash before eating. That helped!
Participants were also questioned if they had anything that affected their eating
or drinking habits that they did not expect. Two respondents (50%) said that yes
something did happen they didn’t expect, one (25%) responded no, and one chose not
to answer. The comments were as follows (Table 5).
36
Table 5. Responses to unexpected experiences
Not unexpected, but food had no taste the last two to three weeks. The doctor had
explained this before treatment began.
Dry mouth, fatigue, irritations, burning sensations, throat very irritated and swollen,
constipation.
Very sore throat and couldn’t hardly swallow, and the food and liquid didn’t have any
taste.
37
CHAPTER 5
DISCUSSION, CONCLUSIONS, RECOMMENDATIONS
Discussion
This study was performed to determine if head and neck cancer patients
received benefit from nutritional counseling. The sample size in this study was too small
to perform any quantitative analysis, but the results did show significant qualitative data.
Of the data collected from the surveys, it was noted that participants did experience
changes in food and beverage consumption patterns during the radiation therapy, but
were able to manage them better with nutrition counseling from the registered dietitian.
The one patient who indicated that he/she had more difficulty with food intake could be
explained by the possibility of that subject having had a longer treatment series then the
other respondents, or simply as treatment continued the pain with eating increased
regardless of consumption of the recommended foods. It should be noted that two
participants answered two of the questions with multiple responses. One expressed
eating less than usual and different foods than usual, and was drinking more fluids than
usual and different fluids than usual. Another was also consuming more fluids than
his/her usual amount as well as different fluids. These multiple responses were unable
to be entered into the SPSS computer program but were important to include. When
different foods or fluids are consumed for comfort, there may be a change in the amount
of calories and protein consumed, ultimately impacting nutritional status.
Taste changes and chewing issues were the most common side effect of
radiation expressed by the respondents. With regard to the registered dietitian helping
38
manage these side effects, one survey was incomplete. The respondent indicated
experiencing side effects but did not respond to whether the registered dietitian had
influenced the management of those side effects which skewed the data. Another
participant also expressed experiencing side effects, but said that the registered
dietitian did not help with any management. It must be noted that in the margin of the
survey the respondent wrote, “She gave us a list of soft foods that helped!” and “He can
eat and drink better a week after radiation stopped.” The data from these questions
were omitted because of not being able to interpret how the respondent felt about the
registered dietitian helping with the management of side effects.
Three participants experienced weight loss, with one patient reporting no weight
loss. At the end of radiation treatment the survey was distributed to subjects and it
asked participants to record weight before and after treatment. Therefore, body weight
and weight changes recorded may not be accurate because of the length of time
between initial measurement and response to survey. The average weight loss was
6.25 pounds. The nutritional counseling offered by the registered dietitian may have
been a factor in keeping this number to a minimum, but there are other factors that
could have also kept this number low including the patients response to treatment as
well as families help and encouragement during meal times. Referring to the literature,
large amounts of weight loss can be detrimental for a cancer patient. Weight loss
increases the risk of morbidity and mortality and being able to keep weight loss at a
minimum would greatly improve the individual’s outcome.
Regarding satisfaction of participants, there was an overall very positive
response. All subjects noted being very satisfied with the nutrition care they received,
39
and three of the four respondents were most satisfied with the registered dietitian’s
assistance in slowing down their weight loss. All participants received written education
material and gave positive feedback reporting that the material was helpful. Energy level
decreases were noted in two participants, but only one gave a positive response
indicating counseling from the registered dietitian had been able to effect his/her energy
level. Many different aspects of cancer treatment can affect energy levels. Radiation
alone can decrease energy levels despite a balanced and adequate nutrient intake.
Nutrition plays a role in energy levels, but overall the assumption was that the registered
dietitian would be unable to increase energy levels entirely with nutrition.
The open-ended question was included in the survey to illicit information
regarding how well informed the patients were to the side effects they could experience
during radiation treatment. This information was important for the treatment facility staff
to determine if they were providing education on each aspect of potential issues that
may arise with treatments. One participant verbalized that the doctor had explained
everything before treatment began, while the other two participants who chose to
answer the question simply mentioned the side effects they had experienced. They may
have chosen to answer the question in this manner because of the severity of the
symptoms or the sudden onset of problems. The researcher theorizes that the side
effects were explained to them, but the information was one of many instructions or
potential problems related to the patient and family before the start of the radiation
treatment.
40
Conclusions
Individuals with head or neck cancer did benefit from nutritional counseling by the
registered dietitian. Patients were able to manage their side effects as well as reduce
the amount of weight lost. Participants were very positive about the nutrition counseling
they received from the registered dietitian. Subjects expressed that the counseling was
beneficial and the education was used; therefore, the assumption was that the quality of
life was improved. Subjects and healthcare professionals had a very good relationship
in this research setting. The registered dietitian was very skilled at building rapport with
the patients and their families in order to give them the most effective nutritional
counseling throughout their treatment. Even though the sample size was small, this
study was an important step in proving that registered dietitians can enhance the quality
of life and nutritional well being of cancer patients undergoing radiation treatment in this
particular setting.
Recommendations
In the future it would be more beneficial to incorporate more than one radiation
treatment facility. It may also be in the best interest to include all cancer patients
receiving radiation therapy for cancer treatment instead of limiting it to only head and
neck cancer patients. Extending the scope of eligible patients would greatly enhance
the data and produce more significant results. I would also recommend to continue the
research by adding a follow-up survey to evaluate how symptoms improve, change, and
affect the remainder of patients’ lives.
41
REFERENCES
1. Facile GA, Whittle KM, Levin LS, Steward DL. A Clinical-Based Intervention Improves Diet in Patients with Head and Neck Caner at Risk for Second Primary Cancer. Journal of the American Dietetic Association. 2005; 105:1609-1612.
2. Allen K, Crocker T. Nutrition Management: An Evidence-Based Integrative Medical Approach for Patients Undergoing Radiation Therapy. Evid Based Integrative Med. 2004; 1:173-182.
3. Capra S, Ferguson M, Reid K. Cancer: Impact of Nutrition Intervention Outcome- Nutrition Issues for Patients. Nutrition.2001; 17:770-772.
4. Isenring EA, Capra S, Bauer JD. Nutrition intervention is beneficial in oncology outpatients receiving radiotherapy to the gastrointestinal or head and neck area. British Journal of Cancer. 2004; 91:447-452.
5. Anderson D, Novak P, Elliot M. Mosby’s Medical, Nursing, and Allied Health Dictionary. St. Louis: Mosby; 2002.
6. Ravasco P, Monteiro-Grillo I, Vidal PM, Camilo ME. Impact of Nutrition on Outcome: A Prospective Randomized Controlled Trial in Patients with Head or Neck Cancer Undergoing Radiotherapy. Wiley InterScience. 2005: 659-668. Available at: http://www.interscience.wiley.com. Accessed October 5, 2006.
7. Nitenberg G, Raynar B. Nutritional support of the cancer patient: issues and dilemmas. Clinical Reviews in Oncology Hematology. 2000; 34:137-168. Available at: http://www.elsevier.com/locate/critrevonc. Accessed on October 5, 2006.
8. Whitman MM. The Starving Patient: Supportive Care for People with Cancer. Clinical Journal of Oncology Nursing. 2000; 4:121-125.
9. Strasser F. Eating-related disorders in patients with advanced cancer. Support Care Cancer. 2003; 11:11-20.
10. Ravasco P. Aspects of taste and compliance in patients with cancer. European Journal of Oncology Nursing. 2005; 9:84-91.
11. Peregrin T. Improving Taste Sensation in Patients who have Undergone Chemotherapy or Radiation Therapy. Journal of the American Dietetic Association. 2006; 106:15361540.
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12. “Proactive.” Dictionary.com Unabridged (v 1.0.1). 2006. Available at: http://www.dictionary.reference.com. Accessed on: October 25, 2006.
13. Thoresen L, Fjeldstad I, Krogstad K, Kaasa S, Falkmer U. Nutritional status of patients with advanced cancer: the value of using the subjective global assessment of nutritional status as a screening tool. Palliative Medicine. 2002; 16:33-42.
14. Scheuren, M. Nutritional support strategies for malnourished cancer patients. European Journal of Oncology Nursing. 2005; 9:74-83.
15. Arends J, Bodoky G, Bozzetti F, et al. ESPEN Guidelines on Enteral Nutrition: Non-surgical oncology. 2006. European Society for Clinical Nutrition and Metabolism. 2006; 25:254-259. Available at: http://www.intl.elsevierhealth.com/journals/clnu. Accessed October 6, 2006.
16. Cheng SS, Terrell JE, Bradford CR, et al. Variables Associated with Feeding Tube Placement in Head and Neck Cancer. Arch Otolaryngology Head and Neck Surgery. 2006; 132: 655-661. Available at: http://www.archoto.com. Accessed October 6, 2006.
17. Daly JM, Hearne B, Dunaj J, et al. Nutritional Rehabilitation in Patients with Advanced Head and Neck Cancer Receiving Radiation Therapy. The American Journal of Surgery. 1984; 148:514-520.
18. Ravasco P, Monterio-Grillo I, Vidal P, Camilo M. Dietary Counseling Improves Patient Outcomes: A prospective, randomized, controlled trial in colorectal cancer patients undergoing radiotherapy. Journal of Clinical Oncology. 2004; 23:1431-1438.
19. Ravasco P, Monteiro-Grillo I, Camilo M. Does nutrition influence quality of life in cancer patients undergoing radiotherapy? Radiotherapy and Oncology. 2002; 67: 213-220.
20. Hartmuller V, Desmond S. Professional and Patient Perspectives on Nutritional Needs of Patients with Cancer. Oncology Nursing Forum. 2004; 31: 989-996.
43
APPENDICES
APPENDIX A
Nutrition Care Survey
Please return survey as soon as possible in the envelope supplied. Please DO NOT
provide your name.
1. Describe your general eating habits since you began radiation treatment. Are they:
______ the same as usual______ more than usual______ less than usual______ different foods than usual
2. After counseling from the Registered Dietitian were you:______ able to eat more______ had more difficulty with eating______ eating about the same
3. Think about what fluids you drink and how much you drink. Since you began radiation treatment, are you drinking:
______ the same as usual______ more than usual______ less than usual______ different drinks than usual
4. After counseling from the Registered Dietitian were you:______ able to drink more______ had more difficulty with drinking______ drinking about the same
5. Has your weight changed since you began radiation treatments? ____Yes _____No
6. What was your weight before your radiation treatment started? _________lbs
7. What was your weight during the last week of your treatments? __________lbs
44
8. On a scale of 1 to 5 with 1 being the least satisfied and 5 being the most satisfied how would you rate your satisfaction with how the Registered Dietitian helped you maintain or slow down your weight loss during radiation treatment?
Least ______1 ______2 ______3 ______4 ______5 Most
9. While you were taking radiation treatments, did something happen that affected your eating and drinking habits that you did not expect?
_________ Yes __________No
Any comments?
10.Do you have any advice to give someone who is beginning the same radiation treatments as you?
11. Have you had any of the following problems? Taste change _____Yes _____NoChewing problems _____Yes _____NoSwallowing problems _____Yes _____NoConstipation _____Yes _____No
45
12. If yes, after counseling from the Registered Dietitian were you better able to manage:
Taste change ___Yes ___No Chewing problems ___Yes ___No Swallowing problems ___Yes ___No
Constipation ___Yes ___No
13. Have you had less energy since your treatment began?_______Yes _______No
14. If yes, after counseling from the Registered Dietitian did you notice a change in energy level:
_____ more energy_____ less energy_____ no change
15.Did you take any nutritional supplements or vitamins during your radiation treatments?
16.Did you receive printed educational materials (pamphlets or hand-outs) from the Registered Dietitian?
______Yes ______No
17. If yes, did you find these materials: _____ helpful _____ not helpful
18. Overall, how do you feel about the nutrition care you received?______Very satisfied______Somewhat satisfied______Somewhat unsatisfied______Very unsatisfied
19. Are you: ______Male ______Female
46
20. Please check your age category:
_____18-25 _____26-35 _____36-45 _____46-55 _____56-65 _____66-75 _____76-85 _____86-95 _____96-105
21. What was your last level of education completed:_____Elementary _____Middle School _____High School _____College _____Other
Please give any additional comments you wish to share:
Thank you so much for participating in this research project! Your responses and comments will help us give better nutrition care in the future. We ask that you return this survey as soon as possible in the envelope that we have provided for you. Please do not include your name.
47
APPENDIX B
Data Analysis
Describe your eating habits since radiation began
Frequency PercentValid
PercentCumulative
Percentless than usual 2 50.0 50.0 50.0Different foods than usual
2 50.0 50.0 100.0
Total 4 100.0
After counseling from the RD were you:
Frequency PercentValid
PercentCumulative
Percent able to eat more 3 75 75.0 75.0 More difficulty 1 25 25.0 25.0
Total 4 100.0 100.0
Since radiation began are you drinking?
Frequency PercentValid
PercentCumulative
Percentmore than
usual4 100 100.0 100.0
Total 4 100.0
48
After counseling from the RD were you:
Frequency PercentValid
PercentCumulative
Percentable to drink more 2 50.0 50.0 50.0drinking about the same
1 25.0 25.0 25.0
Total answered 3 75.0 75.0 100.0
Missing 1 25.0
Total4 100.0 100.0
Have you had taste change?
Frequency PercentValid
PercentCumulative
Percentyes 4 100.0 100.0 100.0Missing 0 00.0
Total 4 100.0
Have you had chewing problems?
Frequency PercentValid
PercentCumulative
Percentyes 4 100.0 100.0 100.0no 0 0.00 0.00
Total 4 80.0 100.0
Have you had swallowing problems?
Frequency PercentValid
PercentCumulative
Percentyes 3 75.0 100.0 100.0no 1 25.0
Total 4 100.0
49
Have you had constipation?
Frequency PercentValid
PercentCumulative
Percentyes 2 50.0 50.0 50.0no 1 25.0 25.0 25.0Total 3 75.0 100.0Missing 1 25.0
Total 4 100.0
Did the RD help with taste change?
Frequency PercentValid
PercentCumulative
Percentyes 2 50.0 100.0 100.0Missing 2 50.0
Total 4 100.0
Did the RD help with chewing problems?
Frequency PercentValid
PercentCumulative
Percentyes 1 25.0 100.0 100.0Missing 3 75.0
Total 4 100.0
Did the RD help with swallowing problems?
Frequency PercentValid
PercentCumulative
Percentyes 2 50.0 100.0 100.0Missing 2 50.0
Total 4 100.0
Did the RD help with constipation?
Frequency PercentValid
PercentCumulative
Percentyes 1 25.0 100.0 100.0Missing 3 75.0
Total 4 100.0
50
Did you experience weight change?
Frequency PercentValid
PercentCumulative
Percentyes 3 75.0 75.0 75.0no 1 25.0 25.0 25.0
Total 4 100.0 100.0
Descriptive Statistics – Weight Loss
N Minimum Maximum MeanStd.
DeviationHow much weight change did you experience
4 .00 12.006.250
06.65207
Did you receive printed educational materials from the RD?
Frequency PercentValid
PercentCumulative
Percentyes 4 100 100.0 100.0Missing 0 0.0
Total 4 100.0
Was the education helpful?
FrequencyPerce
ntValid
PercentCumulative
Percenthelpful 4 100.0 100.0 100.0Missing 0 0.0
Total 4 100.0
Have you had less energy since radiation began?
Frequency PercentValid
PercentCumulative
Percentyes 2 50.0 50.0 50.0no 2 50.0 50.0 50.0Total 4 100.0 100.0Missing 0 0.0
Total 4 100.0
51
Did the RD help with your energy level?
Frequency PercentValid
PercentCumulative
Percentmore energy
1 25.0 25.0 25.0
no change 2 50.0 50.0 50.0Total 3 75.0 75.0Missing 1 25.0
Total 4 100.0
Rate how satisfied you are with how the RD helped you maintain your weight
Frequency PercentValid
PercentCumulative
Percentsatisfied 1 25.0 25.0 25.0most satisfied
2 50.0 50.0 50.0
Total 3 75.0 75.0Missing 1 25.0
Total 4 100.0
How do you feel about the nutrition care you received?
Frequency PercentValid
PercentCumulative
Percentvery satisfied
4 100.0 100.0 100.0
Missing 0 0.0Total 4 100.0
52
VITA
LORI E. WATSON
Personal Data: Date of Birth: September 2, 1983
Place of Birth: Athens, Tennessee
Education: East Tennessee State University, Johnson City, Tennessee;
Family and Consumer Sciences, Concentration: Clinical
Nutrition, M.S., 2007
East Tennessee State University, Johnson City, Tennessee;
Family and Consumer Sciences, Concentration: Dietetics,
B.S., 2005
Professional Registered Dietitian/Nutritionist, Holston Valley Medical Center
Experience: Kingsport, Tennessee 2006- Current
Graduate Assistant, East Tennessee State University, Department
of Family and Consumer Sciences, 2005-2007
Dietetic Intern, East Tennessee State University, 2005-2006
Honors and Tri-Cities District Dietetic Association Outstanding Student of the
Awards: Year 2006-2007
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